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1183 Raritan Road Clark, NJ 07066 |
732-574-9133
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Search for:
Online Photo Estimate Tool
Schedule an Appointment
Services
Forms
Direction to Pay
Work Authorization Form
Auto Pick Up
Our Warranty
Contact Us
Home
Direction to Pay
Direction to Pay
optimaadmin
2022-02-11T08:46:50-06:00
Direction to Pay
J&E Auto Body
1183 Raritan Road, Clark NJ
Phone 732-574-9133 Fax 732-574-3470
Tax ID # 222-033-066
NJ Licenses 00090A
Insurance Company
Customer Name
Claim Number
Consent
(Required)
I agree
You are authorized to forward payment for repairs and or supplement DIRECTLY to J&E Auto Body 1183 Raritan Rd Clark, NJ 07066.
Total Repair Cost
Less Deductible (Customer Responsibility)
Less Betterment (Customer Responsibility)
Balance Due from Insurance Company
Print Name
(Required)
First
Last
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
I agree
Any checks received by a claimant or insured must be turned over to J&E Auto Body. Any attempt to withhold payment after signing this document could result in the claimant or insured being charged the insurance fraud and fined. To ensure payment for the above repair balance, I acknowledge the J&E Auto Body has a mechanics lien on my vehicle until all such repairs cost have been paid. I further agree to pay reasonable attorney's fees, court costs and interest in the event that legal action is necessary.
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